• Single payer does not equal increased wait-times

    I can’t count the number of times I’ve been told this week that it’s just a “fact” that single payer systems lead to increased wait times. It appears that pointing out that this is not true is “rude”. So be it.

    Let’s start with some simple facts. Wait times occur when there are too many patients and too few appointment slots. That can happen when there are too few doctors or when there are too many people who want appointments. So, yes, if you have a doctor shortage, you can get increased wait times. If the system wants to keep spending low by limiting visit slots, you can get increased wait times. If you increase the number of insured people dramatically, you will get increased wait times.

    Note that any of those things can occur with or without a single payer system. They can occur with an entirely private system. If you massively decrease the number of uninsured, as the ACA will attempt to do, it’s entirely possible we will get wait times. This will happen whether people become insured through private insurance in the exchanges or through government insurance (Medicaid). The type of insurance is irrelevant. If there are way more patients calling for appointments, and the number of doctors is static, wait times will likely increase.

    So if wait times are your main concern, then you’re likely against reducing the number of uninsured by any means. The outcome is the same.

    None of this has anything to do with single payer.

    Now it’s possible that single payer systems can lead to increased wait times. In Canada, they keep spending far below what we put out. They do so partially by spacing out visits for elective procedures and such. That’s a conscious decision, and it leads to some people waiting for elective care. But that’s an outcome of their financial conservatism, not the single payer system. Other countries (think France) don’t have the same issues with elective procedures because they spend more money. Our single payer system (Medicare) has far fewer spending restraints, and does not suffer from the wait time problem.

    We could convert the entire country to Medicare tomorrow, increase the number of physicians, and have no wait times at all. We could convert the entire country to private insurance in a Switzerland-like system, make no changes to the number of physicians, and see wait times go through the roof. This really is a zombie idea.

    @aaronecarroll

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    • In comparing my experience with doctor visits in the US and in Switzerland, can can add one data point to the observation that wait times are significantly longer in the US. This applies to both primary care and specialty care.

      Following your argument, I think that implies a better supply of physicians, relative to population, in Switzerland.

      What puzzles me is this: WHY is there a lower supply of physicians, relative to demand, in the US? Physicians in Switzerland get significantly lower incomes than those in the US, so the incentives for joining the profession would seem to be less.

      (see, for example http://economix.blogs.nytimes.com/2009/07/15/how-much-do-doctors-in-other-countries-make/)

      I am sure that part of the story is the relatively lower costs for pursuing advanced degrees in Switzerland, but those are lower across the board, not just in medicine.

      • Isn’t the supply of doctors in the US artificially limited? My impression was that it was really hard to get into medical school, most people who apply don’t get in, and a lot of people who wanted to get in but didn’t would have made fine doctors. And that there are limits on the number of immigrant MDs.

        This may need to change if we decide to provide medical services to more people.

    • I’d also be genuinely interested to see a graph comparing US wait times for those on Medicare, Medicaid, and private insurance. Not sure if such data is readily available though.

      I’m also curious as to how increased spending directly reduces wait times. Is it simply through having more physicians? I wonder how much of the relative lack of doctors in the US comes down to the cost and time requirements for medical school. Is med school in the US more difficult than it is elsewhere? Does that produce “better” doctors, however you prefer to define that term?

      Appreciate the data, Aaron (love the site!). I just think that unfortunately we’ve got a large segment in this country who are conditioned to believe anything “their guy” says without challenging themselves or their version of the facts. Hopefully your posts on this site and your articles on CNN are helping bring relevant information to those who consider themselves to be undecided regarding issues of healthcare access.

    • Wait times, in addition to the massive inconsistency in how they are measured, are highly localized problems. They are specific to procedures (e.g., Hip/Knee surg), or sub-populations, or sub-regions (poor or under-resourced areas), or institutional factors (medicine beds overutilized, ICU transfers) etc. There is no meaningful way to attribute suitable access rates to any one country’s health care system.

      http://www.ncbi.nlm.nih.gov/pubmed/20351538

      http://www.internetgroup.ca/clientnet_new/docs/CIM12_3_Silvester.pdf

    • It’s hilarious to see conservative economists decrying long wait times in countries with nationalized healthcare (for reasons beyond the fact that it’s rarely true and, as you point out, is not a necessary result of nationalization or something that’s absent in private systems). Achieving wait times of zero is very, very rarely the optimum way to spend money on health care. Non-zero wait times shouldn’t be limited to elective procedures, either. Aiming for zero wait times makes sense for emergency care and diagnostics important to analyzing epidemics (and even then, not always). There are probably other things here (I’m no health care expert), but I suspect the ideal wait time for almost all procedures is greater than zero.

    • We could convert the entire country to Medicare tomorrow, increase the number of physicians

      Good point the waiting problem is more connected to the supply restrictions that we have so we should try to reduce the supply restrictions. The states should make it easier for one to become an MD, RN, LPN, NP, PA etc. We should also eliminate restrictions on who can do what.

    • It’s worth noting that OECD data shows that the US and Canada both have 2.4 Practising doctors per 1 000 population, 2009 data. See http://tinyurl.com/cfzmxn7

      There is a big difference in the composition of the physician workforce though. In Canada almost 43% are GPs compared to only 12.% of physicians in the US. Also OECD data at http://tinyurl.com/d2po48l

      The preponderance of specialists is just one reason US health care is so expensive.

    • In some cases in other countries, what we would consider wait times are actually deliberate delays in performing procedures acutely that may become unnecessary if some time is allowed to pass. This especially applies to joint replacement, back surgery, coronary artery procedures, and diagnostic tests that are what we used to call “trolling” for answers to amorphous patient problems, usually with the assumption that finding anything was highly unlikely.

      Applying a little “tincture of time” often clears or drastically improves these sorts of problems. Wait times for procedures and things like CT and MR are often a built in part of the system that facilitates that approach, resulting in fewer procedures and surgery, better health results for patients in the long run, and, of course, reduced costs for the system.

    • Most of the “evidence” for increased wait times seems to be anecdotal, usually 2nd-hand stories of Canadian friends going to America for treatment. Unfortunately, this meme is pretty well-entrenched, and absent better data, this is likely to remain conventional wisdom.

    • “We could convert the entire country to Medicare tomorrow, increase the number of physicians, and have no wait times at all.”

      Only we can’t increase the number of physicians tomorrow, Aaron. This is the US’s main problem: we have a constrained number of ultra-highly compensated physicians who can command massive payments for the services they deliver. The European systems not only have more physicians per capita, but the barriers to become a physician (both in education and in cost) are dramatically lower. The ACA may increase the number of individuals who are nominally insured, but it does very little to fix the supply side of the program, so wait times (particularly for Medicaid patients) will increase.

      David, the Swiss physicians are compensated less because there are more of them. You have cause and effect backward. The US would see lower compensation as well if there weren’t so many barriers to the field (plus limits on what mid-levels can do).

      • The supply of per capita supply of physicians in the US increased by at least 40% in the last 50 years. Areas in the US with larger numbers of physicians have higher, not lower costs and the effect on physician income is negligible if it exists at all. If the supply of MDs is what determines compensation, why don’t Canadian MDs make just as much as American MDs? Why wouldn’t a solo practice doc in Elkhorn MT make more than a derm in NYC?

        And the idea that midlevels are being oppressed by limits on scope of practice is also out of date.

      • NPs can do the exact same thing as MDs in the states of Washington and Oregon.

    • Wait times can also be affected by the way doctors practice, not just supply. We see some of the longest wait times in Massachusetts, the state with the highest rate of full time equivalent primary care physicians.

      StevenH is correct, increasing the number of physicians does not reduce their incomes, and it raises the amount we pay per capita in regions with high supply of physicians.

      One last observation: wait times in the U.S. are often worst in regions where physician supply is highest (such as Los Angeles). The solution is not necessarily more doctors, its a different way of practicing.

      • Massachusetts has among the highest demand for physician services, while Canada has done much to constrain that demand. Supply is only a meaningful concept relative to demand. And relative to demand, increases in physician supply will (must) drive average compensation down. If you increased the national supply by 30%, are you really arguing that average compensation will increase? Where will that money come from? What if supply were doubled? Tripled?

        • Your questions highlight the incredulity that people used to thinking in conventional economic market terms invariably experience when they look at US health care, since it makes a complete shambles of classic supply and demand and market theory.

          Obviously, we do not know what would happen if we doubled or tripled the number of US physicians or physician surrogates. We do know what would happen if we increased supply by 30%, since we did increase supply by more than that in the last three decades of the last century. As you certainly know, that increase was accompanied by runaway increases in both health care costs and physician income.

          We do have examples of individual areas in the US where there are ratios of from two to three times as many physicians per population than other areas. These high density areas always have much higher health care costs per person than the low density areas. The high density is also usually associated with worse health care results than in lower density areas.

          Finally, the importation of foreign medical graduates has not helped control health care costs or make physician distribution more rational. In fact, FMG’s have a greater tendency than American medical graduates to practice in high physician density areas. Even J-1 visa programs designed to place FMG’s in areas of need are not very successful in inducing more rational distribution, since most of the recipients move to higher density areas after finishing their obligatory time in areas of need.

          The only experience with stopping all these trends is in other countries where government regulation forces more rational behavior.

          • “We do know what would happen if we increased supply by 30%, since we did increase supply by more than that in the last three decades of the last century.”

            Please explain why you believe that the supply of physicians is leading to an increase in demand for their services rather than the opposite. How do increases in demand from the last three decades of medical technology and pharmaceuticals fit into this narrative?

            The best relevant analysis I’m aware of is the recent study by Reschovsky et al. suggesting that the increased spending in high-cost areas is being driven by health status and not by supply-sensitive care.

            http://onlinelibrary.wiley.com/doi/10.1111/j.1475-6773.2011.01242.x/full

    • “Please explain why”

      “I see what actually happened, but how does it work in theory?”

      I am not talking about theory here. I am talking about facts on the ground — what really happened.

      It certainly may be that there are other factors, including technical innovation, that have led to increases in spending in the face of increases in the physician to population ratio. However, it remains true that in actual experience, both over time in the last century and over space even now, has shown that in the US an increase in physician to population ratios has always led to increased costs per patient and overall. Although technical innovation has increased over time, access to technical innovation in health care is more or less evenly distributed in space in the US.

      If I were to suggest a theory, I would suggest market breakdown due to very severe asymmetry in information allows physicians to keep themselves busy and well paid by providing enough services to do that. Data about amount of service provided per patient supports that theory, with service ordered per patient — everything from office visits to ICU stays and surgery — increasing with the ratio of physicians to patients. Data on outcomes of care suggests that this is not driven by providing more effective care — quite the opposite, in fact.

      There are certainly theoretical economic arguments to support the idea that physician supply should decrease costs through market competition. However, the fact is that up to this point — with the exception of elective cosmetic procedures which seem to operate by different economic rules than the rest of health care — increases have not accomplished that and have actually been associated with the opposite results.

      It may be that sometime in the future something different might happen, but for now my thinking is driven by the old saying that the definition of insanity is doing the same thing over again and expecting different results.

    • “I see what actually happened, but how does it work in theory?”

      These are not my words; nor do they express my intent.

      “an increase in physician to population ratios has always led to increased costs per patient and overall”

      Replace “led to” with “been associated with” and we’re talking facts. Your post-hoc story is “led to”. Again, what data supports the causal relationship? The Dartmouth Atlas? How do you contrast their results with the Reschovsky work?

      • You are correct, I should have said “associated with.” Careless of me. Noticed that myself but had already posted it.

        I agree that any discussion of causality is worthless without prospective controlled research. Otherwise we are just stuck with observations. The pertinent observation is that whenever physician to population ratios have risen in the US, rises in cost have been associated. Consequently, suggesting that increases in numbers of physicians would lower costs is questionable at best, since the opposite trend has always been observed.

        The Dartmouth data is a major source of material documenting this association, but obviously is not conclusive.

        As to the Reschovsky, it does offer an alternative hypothesis for cost changes over time, but does not offer anything to cover cost changes in different locations at the same time. Health care technology diffuses very rapidly, and is the same in Minnesota and Utah as it is in South Florida and the New York City area. There is, however, a significant difference in cost of health care, and the higher cost areas have higher physician to population ratios.

        I personally do not believe that physician numbers are the major cause of this difference in costs. I believe that differences in physician and institutional culture and in institutional integration and control are more important. Observations support that too, but obviously can’t prove it without prospective controlled study.

        I do, however, believe that increasing numbers of US physicians would not have a positive effect on costs.